Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Pre-Operative Assessment Form
Pre-Surgery Assessment Please complete the following form to help us assess your readiness for surgery.
Full Name *
Date of Birth *
____ / ____ / ________
Do you have any allergies to medications? *
Have you experienced any of the following in the past 6 months? *
- Chest pain
- Shortness of breath
- Palpitations
- Recent illness
- None
Current Medications *
Do you have a history of any previous surgeries?
Signature
Date
Pre-Operative Assessment Form template from formisoft.com. formisoft.com/intake-templates/pre-operative-assessment